Painful diabetic neuropathy

Abstract

Painful diabetic neuropathy affects the quality of life and has no curative therapy. It manifests mainly as burning, pins and needles sensation starting in the feet and progresses upwards. It has established metabolic and vascular pathophysiologic mechanisms. Recent studies try to combine these mechanisms in one big scheme. The diagnosis is mainly clinical. Electrophysiologic studies and skin biopsy plays a supportive role. The physician needs also to exclude other etiologies, commonly encountered in diabetics, such as neuropathies from alcoholism, vitamin B12 deficiency, and uremia among others. Although many screening tests were introduced over the decades, the tuning fork test is still the simplest and widely used. The treatment is multidisciplinary. While tight glycemic control is the main pillar of prevention, drugs are the only proven treatment. Duloxetine and pregabalin are the only FDA approved medications for PDN. Generally, antidepressants and anticonvulsants are the most commonly used. Rational polypharmacy has recently emerged as a necessary way to decrease the effective dose of the prescribed drugs while benefiting from its synergistic outcome. This way we can spare the patient an array of unpleasant side effects. These are the main reason behind medical noncompliance. Lifestyle modifications produce subjective well being. Physical and occupational therapy help patients cope with pain among other benefits. Finally, several authoritative medical associations have published guidelines for therapeutic approach to PDN. It cannot be overemphasized that the approach needs to be individualized.